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Acta Poloniae Pharmaceutica Drug Research, Vol. 71 No. 1 pp.

1123, 2014

ISSN 0001-6837
Polish Pharmaceutical Society

PARACETAMOL: MECHANISM OF ACTION, APPLICATIONS


AND SAFETY CONCERN
MARTA JWIAK-BBENISTA* and JERZY Z. NOWAK
Department of Pharmacology, Chair of Pharmacology and Clinical Pharmacology
at the Medical University of d, eligowskiego 7/9, 90-752 d, Poland

Abstract: Paracetamol / acetaminophen is one of the most popular and most commonly used analgesic and
antipyretic drugs around the world, available without a prescription, both in mono- and multi-component preparations. It is the drug of choice in patients that cannot be treated with non-steroidal anti-inflammatory drugs
(NSAID), such as people with bronchial asthma, peptic ulcer disease, hemophilia, salicylate-sensitized people,
children under 12 years of age, pregnant or breastfeeding women. It is recommended as a first-line treatment
of pain associated with osteoarthritis. The mechanism of action is complex and includes the effects of both the
peripheral (COX inhibition), and central (COX, serotonergic descending neuronal pathway, L-arginine/NO
pathway, cannabinoid system) antinociception processes and redox mechanism. Paracetamol is well tolerated drug and produces few side effects from the gastrointestinal tract, however, despite that, every year, has seen
a steadily increasing number of registered cases of paracetamol-induced liver intoxication all over the world.
Given the growing problem of the safety of acetaminophen is questioned the validity of the sale of the drug
without a prescription. This work, in conjunction with the latest reports on the mechanism of action of paracetamol, trying to point out that it is not a panacea devoid of side effects, and indeed, especially when is taken
regularly and in large doses (> 4 g/day), there is a risk of serious side effects.
Keywords: paracetamol, acetaminophen, toxic effects, mechanism of action, cyclooxygenase, cannabinoid,
serotonergic, prostaglandin-endoperoxide synthases

Paracetamol (an international name used in


Europe) and acetaminophen (an international name
used in the USA) are two official names of the same
chemical compound derived from its chemical name:
N-acetyl-para-aminophenol (the segment cet
inserted between para and amino) and Nacetyl-para-aminophenol. This drug has a long history and, as it often happens with important discoveries, it was found by chance. In the 80s of the 19th
century, two young doctors at the University of
Strasburg, in order to eradicate worms by mistake
dispensed acetanilide to a patient instead of naphthalene (Fig. 1). They noticed that the drug had a small
impact on intestinal parasites, however, it significantly decreased high temperature. Young doctors Arnold Chan and Paul Heppa - quickly published
their discovery and acetanilide was introduced into
medical practice in 1886 under the name of
antifebrin (1). Soon it appeared that although the production of this drug was very cheap, acetanilide

Figure 1. Chemical structure of analgesics - aniline derivatives.


Phenacetin until the 80s of the 20th century was included in the
composition of numerous mixtures. Saridon (Roche firm) and the
so-called in Polish tablets with cross produced by Polpharma
SA in Starogard Gdaski (previously Starogardzkie Zakady
Farmaceutyczne Polfa) and Marcmed from Lublin are the most
well-known preparations. Due to its carcinogenic action damaging
the kidneys and the liver as well as the patients tendency towards
an overuse, the drug was withdrawn from the American market in
1983 (in Saridon, phenacetin was replaced by paracetamol). In
Poland, it happened as late as in 2004

* Corresponding author: e-mail: marta.jozwiak-bebenista@umed.lodz.pl; phone/fax: +48 42 639-32-90

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MARTA JWIAK-BBENISTA and JERZY Z. NOWAK

Figure 2. Paracetamol on the WHO analgesic ladder (the rules for using analgesics, which consider individual intensity of pain).

could not be used as an antipyretic medicament due


to its high toxicity, the most alarming of which was
methemoglobinemia. This resulted in a great deal of
research on less toxic derivatives of acetanilide.
Phenacetin and N-acetyl-p-aminophenol appeared to
be the most satisfying compounds, which had been
earlier synthesized by Harmon Northrop Morse in
1878 (Fig. 1) (2). The first clinical trials with those
two acetanilide derivatives were performed by a
German pharmacologist Joseph von Mering. On the
basis of the obtained results, a faulty conclusion was
drawn that paracetamol was characterized by high
toxicity similar to acetanilide, therefore phenacetin
was the first derivative to be introduced into medical
practice in 1887. Phenacetin was widely used in
analgesic mixtures until the time when it was associated with the development of analgesic nephropathy
after a prolonged usage (3). In Poland, phenacetin
was used as a component of very popular and available everywhere analgesic tablets with the cross.
In fact, acetaminophen/paracetamol became popular
half a year later in 1948 when Bernard Brodie and
Julius Axelrod demonstrated that paracetamol was
the main active metabolite of acetanilide and
phenacetin responsible for their analgesic and
antipyretic action and that methemoglobinemia was
induced by another metabolite, phenylhydroxylamine (4). That discovery revolutionized the pharmaceutical market of analgesic drugs and since then
paracetamol has started its staggering career.

The use of paracetamol


Paracetamol was introduced into the pharmacological market in 1955 by McNeil Laboratories as
a prescribed analgesic and antipyretic drug for children under its trade name Tylenol Childrens Elixir
(the name tylenol derives from its chemical name
N-acetyl-p-aminophenol). One year later, 500-mg
tablets of paracetamol were available over the
counter in Great Britain under the trade name of
Panadol, which were produced by Frederick Stearns
& Co, the branch of Sterling Drug Inc. In Poland,
paracetamol became available in 1961 and since
then it has belonged to the one of the most frequently sold analgesic medications. There are about a 100
preparations in the trade offer, which contain paracetamol alone or in combination with other active
substances.
The paracetamol place on the WHO analgesic
ladder, which precisely defines the rules for application of analgesic drugs, is impressive. This drug has
been placed on all three steps of pain treatment
intensity. In different pains of moderate intensity,
paracetamol as a weak analgesic together with nonsteroidal analgesic drugs or coanalgesics (e.g., caffeine) is a basic non-opioid analgesic (the first step
of the analgesic ladder). When pain maintains or
increases, paracetamol is used as an additional analgesic with weak (e.g., caffeine, tramadol) or strong
(e.g., morphine, phentanyl) opioids from the second
and third step of the analgesic ladder, respectively,

Paracetamol: mechanism of action, applications and safety concern

Fig. 2). Paracetamol, if efficient, is a recommended


oral analgesic of a first choice to be used for a long
time, e.g., in symptomatic treatment of slight and
moderate pain occurring in osteoarthritis as well as
in muscle or tendon pains. Moreover, it is a drug of
choice in patients in whom application of nonsteroidal anti-inflammatory drugs (NSAIDs) are
contraindicated, e.g., in the case of gastric ulcers,
hypersensitivity to aspirin, impairments in blood
coagulation, in pregnant women, nursing mothers
and children with fever accompanying a disease (5).
The use of paracetamol in children requires special
care and maintain in an adequate dosage (based on
age), which significantly differs from standard adult.
The recommended dosage for children consider the
metabolism of paracetamol, which determines the
toxicity of the drug, especially hepatotoxicity (see
below). In children, paracetamol metabolism
changes with age: in younger children the sulfation
pathway is dominated route of paracetamol elimination (which is mature at birth); the glucuronidation
pathway takes about two years to mature. The oxidation of paracetamol, which takes place mainly
with the participation of the enzyme CYP2E1 in
neonates is negligible, because the activity of
CYP2E1 increases with age, reaching the adult
value at age 1-10 years. For comparison, in adults,
paracetamol is metabolized mainly in the liver via
glucuronidation (50-60%), sulfation (25-30%) and
oxidation (< 10%) (see below in the section on
adverse effects). Therefore, according to Ji et al. (6),
the proposed dosage of paracetamol in children up
to 12 years is as follows:
under 2 years no recommended dose; treatment
under the supervision of a physician;
2-3 years 160 mg (daily dose divided into two
dose units, i.e., 2 80 mg); total dose corresponds
to 1/2 of a single dose for an adult, i.e., 325 mg;
4-6 years 240 mg (daily dose divided into three
dose units, i.e., 3 80 mg); total dose corresponds
to 3/4 of a single dose for an adult;
6-9 years 320 mg (daily dose divided into four
dose units, i.e., 4 80 mg); total dose is the same
as a single dose for an adult;
9-11 years 320-400 mg (daily dose divided into
four-five dose units, i.e., 4-5 80 mg; total dose
corresponds to 1-1 1/4 of a single dose for an
adult;
11-12 years 320-480 mg (daily dose divided in
the four-six dose units, i.e 4-6 80 mg; total dose
corresponds to 1 1 1/2 of a single dose for an
adult.
According to the 20th edition of Drugs of
Contemporary Therapy (Polish), the acetaminophen

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dosage schedules in pediatric patients should be as


follows: 10-15 mg/kg oral dose and 15-20 mg/kg
rectal dose every 4-6 h, maximum of 5 doses/day; in
newborns orally or rectally 10 mg/kg of body weight
every 4 h or 15 mg/kg every 6 h (maximum daily
dose in newborns is 60 mg/kg).
Mechanism of action
Although paracetamol was discovered over
100 years ago and has been widely used in medical
practice for more than half the century, its mechanism of action has not been elucidated until now (7).
It has analgesic and antipyretic properties similarly
to NSAIDs, but contrary to them, it does not possess
any anti-inflammatory activity. When applied in
recommended doses, it does not induce typical for
NSAIDs gastrointestinal side effects. However, it
suppresses prostaglandin production likewise
NSAIDs.
Due to lack of an anti-inflammatory component, paracetamol has not been regarded as a member of the NSAIDs family in pharmacological textbooks, although what is interesting, it has been
always discussed together with these drugs.
Therefore, the discussion on the mechanism of
action of paracetamol should begin from the analysis of NSAIDs action.
All conventional NSAIDs inhibit the convertion of arachidonic acid (AA) into prostaglandin H PGH2. The stage is catalyzed by prostaglandin H
synthase (PGHS), at present referred to as cyclooxygenase (COX) within which isoenzymes COX-1
(PGHS-1) and COX-2 (PGHS-2) occur (8). The
prevalence and the role of the third isoenzyme
COX-3 is the subject of ongoing to date discussions
(read further). PGHS is a bifunctional enzyme and
possesses two different enzymatic activities:
cyclooxygenase and peroxidase (POX). The conversion of AAPGH2 involves two reactions: cyclization of AA to unstable 15-hydroxyperoxide (PGG2)
with the involvement of a cyclooxygenase component and double oxidation in position 9 and 11;
whereas the reduction of PGG2 molecule to its 15hydroxy analogue, unstable structure of PGH2, takes
place due to peroxidase activity of PGHS (POX).
Prostaglandin H2 (PGH2) is a substrate for specific synthases, tissue-dependent isomerases
catalysing its further conversions into different
endogenous regulators, namely: prostaglandins of the
D (PGD2), E (PGE2), F (PGF2) series and prostacyclin
(PGI2; prostacyclin is not a prostaglandin and a commonly used abbreviation is historically conditioned)
and thromboxanes (TXA2 and TXB2). They all are
characterized by different biological activity and

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MARTA JWIAK-BBENISTA and JERZY Z. NOWAK

many of them have anti-inflammatory properties.


Thus, the action of NSAIDs, which inhibits the stage
of conversion AAPGH2, and also the formation of
the aforementioned regulators, have some favorable
(anti-inflammatory, analgesic and antipyretic) and
side effects (associated with the inhibition of synthesis of particular regulators in different tissues). A precise mechanism of NSAID action together with therapeutic and side effects has been presented in the
recently published large study by Nowak and
Dzielska-Olczak (9) and Nowak (10, 11).
While traditional NSAIDs and selective COX2
inhibitors inhibit cyclooxygenase (PGHS) through
competing with arachidonic acid for the active site of
the enzyme (12), paracetamol is likely to act as a factor reducing a ferryl protoporphyrin IX radical cation
(Fe4+=OPP*+) within the peroxidase site of the PGHS
enzyme. In turn, the Fe4+=OPP*+ generates tyrosine
radicals in the place of PGHS cyclooxygenase,
which are essential for catalyzation of AA oxidation
reaction (12-16) (Fig. 3). Due to a fact that hydroperoxides of fatty acids, like PGG2 (reduced by POX),
oxidize porphyrin within the peroxidase site of the
enzyme, cyclooxygenase inhibition by paracetamol
is difficult in the presence of high peroxide levels.
Graham and Scott suggested that paracetamol should
be classified to the group of the so-called atypical
NSAIDs, determined as peroxide sensitive analgesic
and antipyretic drugs (PSAAD) (17).
For the last decades, it was thought that paracetamol reveals analgesic and antipyretic properties
by acting centrally and its inhibitory effect on COX1 and COX-2 activity, i.e., prostaglandin synthesis
was low. This concept was based on the original
research carried out by Vane and colleagues, which
was published at the beginning of the 70s of the previous century. Those authors observed that parac-

etamol decreased prostaglandin synthesis ten times


stronger in the brain than in the spleen (18).1
At that time COX isoforms were not known
because isoenzyme, COX-2, was identified only at
the beginning of the 90s of the previous century (25,
26). Ten years later, the experiments performed on
the dogs brain tissue revealed the presence of the
third COX isoform, COX-3, which demonstrated
special sensitivity to paracetamol (27). However, it
soon appeared that so sensitive to paracetamol
COX-3 does not function in the human organism.
The human analogue of dogs COX-3, which occurs
in some tissues especially of the central nervous system, is an alternative splice variant of COX-1 without a preferential sensitivity to paracetamol, encoding proteins of amino acid sequence different from
COX and not exhibiting COX activity (28-30).
Thus, COX-3 involvement in the mechanism of
action of paracetamol in humans has not been justified, which has been confirmed by Kis et al. as well
as by Hinz and Brune (15, 29). However, the discussions regarding a potential role of identified three
COX isoenzymes in the mechanism of paracetamol
action are still being continued (31-34).
The concept regarding COX-dependent central
mechanism of paracetamol action has not stood the
test of time (29). Firstly, the studies by Graham and
Scott have shown that paracetamol really inhibited
prostaglandin synthesis in well-functioning cells,
however, it did not exert the same effect in the tissue/cell homogenate, where the concentration of
arachidonic acid is low (35). Secondly, paracetamol
has been found to have an inhibitory impact on
COX-1 and COX-2 activity in peripheral tissues,
although not to the same extent, since a stronger
effect was always observed in relation to COX-2,
especially in the cells of the vascular endothelium.

In numerous academic textbooks including those published during the last decade, the central mechanism of paracetamol action has been
discussed emphasizing its weaker inhibitory effect on the cyclooxygenase activity and prostaglandin production as compared to NSAIDs.
The early study by Flower and Vane from 1972 in the prestige magazine Nature announced the mechanism of paracetamol activity even
in its title: Inhibition of prostaglandin synthetase in brain explains the antipyretic activity of paracetamol (4-acetamidophenol) (18).
Scientific prestige of the future Nobel prize winner, John R. Vane, was so high that despite later published articles, which did not completely confirm the original results of the British researchers (19-21) that study was still citied and its results were considered the substantial basis of the mechanism of paracetamol action for many pharmacologists and doctors.
Flower and Vane indicated that prostaglandin production in the brain was 10-fold more sensitive to paracetamol action than in the
spleen (18). At that time, John R. Vane, the future Noble Prize winner in physiology and medicine (John R. Vane, Sune K. Bergstrom and
Bengt I. Samuelsson Nobel Prize in 1982 for discoveries on prostaglandin and related biologically active substances) was the author
of many other essential for medicine innovative observations that were published in prestige magazines, e.g. Inhibition of prostaglandin
synthesis as a mechanism of action for aspirin-like drugs (22). John Vane, using a guinea pig lung homogenate in his study, concluded
that analgesic, antipyretic and anti-inflammatory action of aspirin, indomethacin and salicylate is associated with a lower prostaglandin
production resulting from cyclooxygenase inhibition (COX). Other articles published in the same magazine Nature by Vane et al.:
Indomethacin and aspirin abolish prostaglandin release from spleen and by Smith and Willis: Aspirin selectively inhibits prostaglandin
production in human platelets contained the results confirming those observations (23, 24). It is worth remembering that COX isoenzymes
were not discovered at that time.
1

Paracetamol: mechanism of action, applications and safety concern

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Figure 3. The complex of prostaglandin H synthase (PGHS) including two components: cyclooxygenase (COX) and hydroperoxidase
(POX) is a bifunctional enzyme, responsible for the metabolism of arachidonic acid (AA) to prostaglandin PGH2. The reaction occurs via
two stages: 1. AA oxidation to PGG2 depends on tyrosine radical (Tyr385*) in the COX site. 2. PGG2 undergoes reduction to PGH2 in the
POX site, which results in the oxidation of the peroxidase heme radical. 3. A formed ferryl protoporphyrin IX radical cation (Fe4+=OPP*+)
generates Tyr385* radicals. Thus, the POX part is self-sufficient, whereas COX depends on POX. Paracetamol reduces an iron cation in
protoporphyrin IX radical (Fe4+=OPP*+) in the POX part, which contributes to a lower amount of Tyr385* radical formation. Abbreviations:
AA arachidonic acid; AA* arachidonic acid radical; A* - oxidized cosubstrate; AH reduced cosubstrate; Fe3+ - enzyme at rest; Fe4+=O
protoporphyrin IX (heme); Fe4+=OPP*+ - protoporphyrin radical IX; HPETE hydroperoxides of fatty acids; PGG2* - prostaglandin G2
containing peroxide radical; PGH2 prostaglandin H; ROH alcohol; Tyr385* tyrosine radical (12, 16, 38).

Hinz et al. indicated that orally administered paracetamol at a dose of 1 g inhibited 80% of the COX2 activity in human blood monocytes (36). The
results of extensive studies by Hinz and Brune published in the years 2006-2012 reveal that paracetamol is a preferential inhibitor of COX-2 isoenzyme,
however, its effect depends to a great extent on the
state of environmental oxidation/reduction (redox)
(15, 37).
Among other possibilities of the central action
of paracetamol, its stimulating effect on descending
serotoninergic pathways, which are involved in inhibition of pain sensations has been discussed. This
theory has been confirmed by in vivo studies on animals as well as on humans. Alloui et al. carried out
the study on analgesic and anti-inflammatory action
of paracetamol in rats which were given caragenin.
No anti-inflammatory effect of paracetamol was
observed, however, central antinociceptive effect of
this drug with the involvement of the 5-HT3 subtype
of serotonin receptors was detected (38). The study
on healthy volunteers in whom the pain was induced
through electrical stimulation of the median nerve
showed that analgesic action of paracetamol was
completely blocked in the group of subjects treated
with paracetamol combined with tropisetron or
granisetron (5-HT3 receptor antagonists) (39, 40).

Data concerning central action of paracetamol


through its effect on descending serotoninergic pathways do not exclude a hypothesis assuming the presence (or coexistence) of the inhibition of
prostaglandin synthesis (35). Prostaglandin PGE2
modulates numerous physiological processes and
can also modulate nociceptive and autonomic
processes via its influence on descending serotoninergic antinociceptive system (41).
Novel studies on the mechanism of action of
paracetamol regard it as a pro-drug, which due to its
active metabolites demonstrates an association with
the endocannabinoid system. It has been observed
that in mouse brain and spinal cord, paracetamol is
subject to deacetylation to p-aminophenol that in
turn reacts with arachidonic acid affected by fatty
acid amide hydrolase (FAAH), resulting in the formation of an active metabolite of the drug, the fatty
acid amide N-arachidonoylphenolamine (AM404)
(42, 43). AM404 does not act directly on cannabinoid receptors, however, it increases activity of
endocannabinoid system in an indirect way (44). On
one hand, this compound is a strong activator of the
vanilloid receptor subtype 1 (TRPV1), being a ligand of receptors for cannabinoids CB1, and on the
other hand, it leads to an increase in the endogenous
pool of these compounds as an inhibitor of the

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MARTA JWIAK-BBENISTA and JERZY Z. NOWAK

endogenous cannabinoid (anandamide) reuptake


(45). Endogenous cannabinoids, e.g., anandamide,
act antinociceptively both at the level of the spinal
cord as well as the brain. The study on rats performed by Bertolini et al. presented that an earlier
administration of the CB1 receptor inhibited AM404
activity and completely blocked analgesic action of
paracetamol in the animals (46). Moreover, cannabinoids considerably lower body temperature through
the activation of CB1 receptors in the pre-optic area
(47). It has been known that analgesic derivatives of
aniline have a similar action as cannabinoids, such
as mood improvement, psychic relaxation and sedation. Such properties have not been observed so far
in the case of paracetamol, although some authors
ascribe poor sedative properties to it (29, 48).
Furthermore, different concentrations of AM404
have been found to inhibit COX-1 and COX-2
enzymes. This mechanism may be important especially in such areas of the brain in which a high con-

centration of FAAH enzyme can be observed, e.g.,


in the mesencephalic trigeminal nucleus, primary
sensory neurons. In these areas of the brain an
increased production of the active metabolite
AM404 can be found, and this in turn may to a certain degree explain the inhibitory action of paracetamol towards cyclooxygenases in the CNS (46).
Inhibition of nitrogen oxide (NO) formation
might be also an alternative mechanism of analgesic
action of paracetamol. The L-arginine/NO pathway
activated by substance P and NMDA receptors leads
to NO synthesis, which is an important neurotransmitter in the nociceptive processes of the spinal cord
(49, 50).
Summing up, paracetamol acts at all levels of
pain stimulus conduction from the tissue receptors
through the spinal cord to the thalamus and the cerebral cortex in which pain sensations are evoked. The
mechanism of analgesic action of paracetamol is
complex. The following possibilities are still taken

Table 1. Advantages and disadvantages of paracetamol therapy.

Advantages
(when the drug is administered in the recommended therapeutic doses max. 4 g/24 h)
wide therapeutic application
checked and examined
well tolerated
good bioavailability after oral administration (t1/2 2h)
fast elimination
cheep
a small number of interactions with other drugs
low toxicity at low doses ( 2 g / d) to the digestive tract and kidneys
low toxicity in children
rare side effects (main allergic skin reactions)
available in different pharmaceutical forms
Disadvantages
metabolized to a toxic metabolite (N-acetyl-p-benzoquinone imine)
therapeutic index (often not efficient at a low dose)
long-term application may cause:
renal functioning disorder
higher blood pressure
increased prevalence of heart infarction
low therapeutic efficiency
analgesic action at a dose of 1 g administered 2, 3, and 4 times a day
low anti-inflammatory action
hepatotoxicity
increased aminotransferase activity at therapeutic doses
hepatic failure in the case of overuse (two-fold overuse of a therapeutic dose)
enhanced previous liver damage caused by alcohol consumption
combinations with traditional NSAIDs can result in a higher prevalence of digestive tract ulceration

Paracetamol: mechanism of action, applications and safety concern

into consideration: affecting both peripheral (inhibition of COX activity) and central (COX, descending
serotoninergic pathways, L-arginine/NO pathway,
cannabinoid system) antinociceptive processes as
well as the redox mechanism (51). The studies on
the mechanism of paracetamol action require further
verification - they should concern not only the therapeutic action of this drug but also more frequently
reported poisoning, especially strong hepatotoxicity
resulting from the drug overdose since numerous
preparations containing paracetamol are available
without a prescription.
Paracetamol on the pharmaceutical market
Paracetamol is available on the market under
different trade names in simple (sold over the counter) or more complex preparations combined with an
additional active substance obtainable only by prescription (with tramadol) or without it (in combination with codeine phosphate, ascorbic acid or
diphenhydramine hydrochloride as well as NSAIDs
such as ibuprofen or propyphenazone. Paracetamol
occurs in the form of tablets, effervescent tablets,
suspension, powder to prepare oral liquid medicine
(sachets) and rectal suppositories. When administered orally, clinical effect of paracetamol appears
after 30 min. Paracetamol content in oral medicaments differs; most frequently it equals 500 mg,
however, there are preparations (most often complex) which contain 325 mg of paracetamol or 750
mg (e.g., Febrisan, Coldrex) or even 1000 mg (e.g.,
Efferalgan Forte, Codrex MaxGrip, Flucontrol Hot).
The fastest action of paracetamol, already after 15
min, occurs in the case of using fast-release tablets,
enriched with sodium bicarbonate which enhances
stomach emptying. Due to this process, paracetamol
quicker passes to the small intestine where it undergoes absorption (e.g., Panadol Rapid). When
administered rectally (suppositories), bioavailability
of paracetamol is lower, about two thirds of availability as compared to oral administration. The time
necessary to achieve the therapeutic concentration
for suppositories is 120-180 min, which means that
analgesic action occurs after 2-3 h since the drug
intake. Bioavailability and speed of absorption of
paracetamol in the form of suppositories depend on
numerous factors: the drug dose (in adults usually
650 mg; in children 80-325 mg), the size of the suppository (the smaller and the lower dose the better
bioavailability is), the type of vehicle (the higher
vehicle lipophilicity, the greater bioavailability and
the faster effect but the shorter time of drug action)
and the degree of rectal vascularization. Slower
absorption of paracetamol applied via rectum (sup-

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positories) differs from other analgesic medicaments: e.g., sodium diclophenac in the form of suppositories in the preparations Dicloberl (50 mg of
the active substance) or Dicloratio (25, 50 and 100
mg) achieves the maximal blood concentration after
30 min since the application, in the preparations:
Diclac and Diclofenac GSK (50 or 100 mg) or
Voltaren (25, 50, 100 mg) after 60 min, and in
Olfen (50 and 100 mg) after 2 h (data according to
Pharmindex 2012). These data show that the speed
of absorption of an active substance from the drug
administered per rectum (affecting the occurrence of
the therapeutic effect) is influenced by the form and
composition of the adjuvant substances contained in
suppositories; the same factors affect the suppositories containing paracetamol. Slower absorption of
the drug is usually associated with its longer presence in the organism, i.e., with a longer time of
action, which in the case pain complaints is of considerable importance.
Paracetamol can be also used intravenously
(i.v.) and therefore is widely used in the hospital
health service, e.g., in the postoperative pain therapy (it has been evidenced that administration of
paracetamol especially during the first hour of treatment is more efficient in reducing pain intensity
than given orally), in order to quickly decrease high
fever or in the case when another route of administration is not possible (52, 53). At the beginning,
propacetamol precursor of paracetamol (ProDafalgan, Bristol-Myers Squibb; Pro-Efferalgan,
UPSA) was used which after the i.v. administration
underwent hydrolysis to paracetamol and diethylglycine under the influence of plasma esterases. In
2005, an intravenous form of new generation paracetamol was registered as a solution ready to be
infused at the concentration of 500 mg/50 mL or 1
g/100 mL (Perfalgan, Bristol-Myers Squibb) which
completely removed proparacetamol from medical
practice (53, 54).
Side effects
When appropriate dosage of medicaments containing paracetamol is used, i.e., maximum dose of
4 g/24 h, (as one can read in the leaflet) no serious
side effects have been observed, besides possible
allergic skin reactions, although after higher doses
or prolonged duration of taking the drug, some side
effects may occur, especially in the liver (Table 1)
(55). Interesting is that at the beginning of 2013, the
United States Food and Drug Administration (US
FDA) introduced paracetamol on the list of the
preparations, which will undergo specific monitoring on the basis of information from the system on

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MARTA JWIAK-BBENISTA and JERZY Z. NOWAK

adverse reactions (FEARS, the FDA Adverse Event


Reporting System) collected during the period from
October to December 2012. The preparations containing paracetamol will be evaluated in terms of
inducing adverse skin reactions.
After ingestion of paracetamol, about 90% of
the compound undergoes metabolism in the liver in
conjugation with glucuronic acid (50-60%), sulfuric
acid (25-35%) and cystine (approximately 3%) to
form pharmacologically inactive metabolites, which
are eliminated with urine. A small amount of the
drug (about 5%) is eliminated in an unchanged form
by kidneys. Subsequent 5% of paracetamol is subjected to N-hydroxylation in the liver with the
involvement of cytochrome P450 enzymes (particularly CYP2E1) to form a toxic metabolite N-acetylp-benzoquinone imine (NAPQI), which is very
quickly inactivated by glutathione sulfhydryl groups
and excreted with urine as mercapturic acid (46).
Severe liver impairment after paracetamol
overdose was documented for the first time in Great
Britain in 1966 (56). Since then, a steady increase in
the number of accidental or intended poisonings has
been noted all over the world including Poland. The
main cause of this situation is a huge amount of
preparations containing paracetamol, which are
available on the pharmaceutical market without any
prescription (according to the 20th edition of Dugs
of Contemporary Therapy, the number of such
preparations reaches 92 items, including 39 single
and 53 complex products). Depletion of hepatic glutathione stores occurs as a result of the intensive
metabolism following intentional and unintentional
overdose of paracetamol (ingestion of more than 4
g/24 h, i.e., over 8 tablets, 500 mg each!). In such a
situation, paracetamol becomes a dangerous and
life-threatening drug because a highly reactive
NAPQI metabolite covalently binds to hepatocyte
macromolecules leading to impoverishment of
enzymatic systems and structural and metabolic
damage to the liver (potential lethal hepatic necrosis). In the later stage of poisoning, renal tubular
necrosis and hypoglycemic coma may appear (57).
It is worth mentioning that the weakened hepatic
function (caused by slimming, malnutrition, hepatitis C virus (HCV), human immunodeficiency virus

(HIV)), alcohol overuse or application of paracetamol combined with drugs inducing cytochrome
P450 (rifampicin, barbiturates, carbamazepine) can
lead to hepatic impairment much easier, even when
the compound is used in therapeutic doses.
Development of acute hepatic failure as a result of
paracetamol overuse (i.e., 7.5-15 g /24 h) as well as
the methods of its treatment have been precisely discussed in many studies for the last ten years (46, 5860). The authors of the present study concentrate on
other (likely to be potential) adverse reactions of
paracetamol, which result from its mechanism of
action.
Results of recent reports on paracetamol as a
peripheral selective COX-2 inhibitor encourage
researchers to analyze this drug more critically. The
question arises as to whether paracetamol revealing
a similar pharmacological profile to coxibs may
induce the same side effects, especially when the
drug is used for a long time.2 A permanent blockade
of prostaglandin synthesis through selective COX-2
inhibitors is currently regarded as a cause of adverse
cardiovascular reactions in patients after a prolonged use of these drugs (15, 36, 37, 61). Longlasting COX-2 inhibition decreases the production
of vasoprotective prostacyclin (PGI2) by vascular
endothelial cells, which inhibits platelet aggregation
and has vasodilational capacity. This impairs the
balance between tromboxane and prostacyclin and
causes thrombus formation. Contrary to the inflammatory tissue, the endothelial cells possess a low
level of peroxides, so they are not likely to inhibit
paracetamol activity against COX-2 (14).
It has been shown that oral administration of
paracetamol at the dose of 500 mg decreases the
amount of excreted with urine 2,3-dinor-6-keto
PGF1, the main stable inactive metabolite of prostacyclin, whose synthesis is mediated by endothelial
COX-2 (62). Likewise, 50% reduction in this
metabolite excretion in the urine of pregnant women
was noted after ingestion of 1 g of paracetamol (63).
Taking into consideration aforementioned results
obtained by Hinz et al. (36), regarding over 80%
inhibition of COX-2 in the vascular endothelium
caused by paracetamol, it can be speculated that
such a mechanism of action would be responsible

Coxibs, NSAIDs selectively inhibiting COX-2 activity, do not affect (in therapeutic doses) COX-1 at the same time. Due to such a mechanism of coxibs, their side effect on the digestive system, which happens in the case of traditional NSAIDs, was eliminated. However, later
clinical observations indicated that patients using coxibs for a long time developed adverse cardiovascular reactions. Thus, because of a
higher risk of such perturbations in those patients, coxibs (etoricoxib, lumiracoxib, rofecoxib and valdecoxib) have been withdrawn from
sale. Rofecoxib known under the trade name of Vioxx (Merck & Co.) was withdrawn as the first one in 2004 after the 5-year existence on
the pharmaceutical market; valdecoxib (Bextra, Pfizer) was the next drug withdrawn in 2005. At present, only one drug of this type, celecoxib (Celebrex; Pfizer Europe), is used in Poland.

Paracetamol: mechanism of action, applications and safety concern

for adverse cardiovascular reactions in patients who


take this drug regularly. It should be emphasized
that paracetamol due to its short half-life (approximately 2 h) induces a short-lasting inhibition of
COX-2 activity. Thus, in order to eliminate pain it is
necessary to administer repeated 1 g doses of paracetamol for maintaining constant (80%) inhibition of
COX-2. This fact has to be considered by a doctor
prior to making the decision about long-term treatment with paracetamol in order to avoid the drug
overdose.
Epidemiological data reveal that long-lasting
administration of paracetamol affects blood pressure. Nurses Health Studies present two cohort
investigations performed among younger and older
women. One of them demonstrated that in patients
who regularly took paracetamol (over 500 mg/24 h),
a relative risk (RR) for development of hypertension
was considerably higher as compared to women
who did not use this drug (RR 1.93 for older women;
RR 1.99 for younger) (64). Moreover, it worth
emphasizing that the risk associated with paracetamol was similar to traditional NSAIDs (RR 1.78 for
older women; RR 1.60 for younger). The second
cohort investigation carried out in the same study
group indicated that in women who frequently used
paracetamol (= 22 days a month), the risk of serious
cardiovascular events (such as heart infarction or
cerebral stroke) was nearly the same as after traditional NSAIDs (RR 1.35 for paracetamol; RR 1.44
for traditional NSAIDs). Similarly, application of
paracetamol in the amount of 15 tablets or more per
week is associated with the risk of cardiovascular
events comparable to traditional NSAIDs (RR 1.68
for paracetamol; 1.86 for traditional NSAIDs) (65).
According to the guidelines of the American Heart
Association acetaminophen (paracetamol) is nowadays a drug of choice in patients with concomitant
cardiovascular disorders (66). The prospective double-blind trial was performed in patients with stable
coronary disease who used paracetamol at the dose
of 1 g three times a day for two weeks and the drug
increased their blood pressure. Its effect was similar
to that exerted by diclofenac and ibuprofen.
Paracetamol due to its selective action towards
COX-2 and similarly to coxibs but contrary to typical NSAIDs does not possess antiaggregatory
properties. The drug does not inhibit blood platelet
action when taken at a single oral dose of 1000 mg.
However, clinical studies indicate antiaggregatory
action of paracetamol in the case of parenteral
administration in high doses (67, 68). Paracetamol
can be safely used in the digestive tract; on one
hand due to its non-acidic chemical structure

19

(unlike acidic NSAIDs gathering in the gastric


epithelial cells) and on the other hand, due to a
weak impact on COX-1. However, the results of
epidemiological studies suggest that paracetamol at
daily doses higher than 2-2.6 g increases the risk of
serious side effects in the upper segment of the
digestive tract such as bleeding or perforations (69).
Therefore, it is postulated that a long-term effect of
paracetamol on the digestive tract should be examined in randomized studies, especially in patients
with osteoarthrisis who require high doses of this
drug for a long time. Paracetamol like coxibs does
not induce bronchial spasm in patients with aspirin
asthma. In the strategy for treatment of pain in asthmatics, it is recommended to ingest this drug at
doses lower than 1000 mg in order to avoid potential bronchial spasm (15).
Bearing in mind a preferential action of paracetamol on COX-2, the differences between the drug
discussed and coxibs, selective inhibitors of this
isoenzyme, should be emphasized. Paracetamol in
opposition to selective inhibitors of COX-2, despite
a similar mechanism of action, reveals weak antiinflammatory activity. It is likely to result from the
extracellular accumulation of arachidonic acid and
peroxides in the inflammatory tissues, which reduce
an inhibitory effect of paracetamol on the
prostaglandin production (Fig. 3) (14, 35). Indeed,
paracetamol did not decrease prostanoid concentrations in the joint fluid of patients suffering from
osteoarthrisis (70). On the other hand, paracetamol
reduced tissue swelling with similar to ibuprofen
efficiency after the oral cavity surgery in humans
(71). There have been also some studies which
demonstrated anti-inflammatory action of paracetamol, e.g., nociceptive inhibition and carrageenaninduced rat paw edema (72). Therefore, the notion
that paracetamol exhibits weak anti-inflammatory
properties seems to be more legitimate than the
assumption that this drug is devoid of such an
action.
As regards safety of paracetamol application in
pregnancy, prospective cohort studies in humans
have not shown an increase in the prevalence of
developmental fetal anomalies in pregnant women
who took paracetamol in therapeutic doses, although
in some experimental studies on animals paracetamol administered at doses twice as high as the maximum single dose demonstrated embriotoxic action
(73). Considering the fact that paracetamol is the
drug of choice in pregnant women, it should be
emphasized that epidemiological studies report the
possibility of the association between application of
this drug in pregnancy and development of asthma

20

MARTA JWIAK-BBENISTA and JERZY Z. NOWAK

in early childhood. The metabolism of paracetamol


has been suggested to be responsible for this effect
because a large amount of glutathione is used to
deactivate the toxic metabolite. Lungs of the developing fetus might deplete glutathione, the main
antioxidant of this organ, which can lead to oxidative stress and inflammation of the respiratory airways. In some investigations, the occurrence of
wheezing breath in very small children was
observed, which however, is a very weak indicator
of asthma (74). Epidemiological studies from different research centres provide controversial results on
the association between paracetamol ingestion by
pregnant women and the development of bronchial
asthma later in childhood (74, 75). This happens
because a number of other factors such as fever,
cold, inflammation of fetal membranes or other
infections of pregnant women can induce development of asthma in small children, leading thus to falsification of study results. Thus, a randomized study
with placebo as a control could solve this problem.
However, such a study would be unethical from the
point of view of good clinical practice (GCP) which
requires application of a standard drug as a comparator, and as NSAIDs are contraindicated in pregnancy, one group of women with pain and fever
would not be treated at all. At present, there is no
convincing evidence allowing to unequivocally
determine that application of paracetamol in pregnant women may lead to asthma development in
small children. Therefore, paracetamol still remains
an analgesic and antipyretic drug of choice in pregnant patients. However, it should be stressed that
the aforementioned data do not concern complex
preparations containing paracetamol or those for i.v.
infusion (safety for this route of administration has
not been determined due to lack of sufficient clinical data).
Precautions and attempts to counteract toxicity
of paracetamol
Due to an easy overdose of paracetamol, the
US FDA has proposed to implement new solutions,
which to a certain degree would limit this growing
problem. A decrease in the maximum permissible
single dose of paracetamol from 1000 mg to 650 mg
seems to be one of the crucial problems. Thus, a
question arises what will happen to numerous OTC
preparations containing paracetamol in the dose
exceeding 650 mg. It has been suggested that higher doses of this drug, i.e., above 325 mg should be
available only by prescription (according to the
information of the US FDA; www.fda.gov).
Another suggested solution postulated by FDA is

the withdrawal of packages containing high amounts


of paracetamol from the market, e.g., containers
comprising even 100 single doses (e.g., Apap - 100
tablets, Codipar - 50 tablets), and the introduction of
blisters that should enable the patient to control the
amount of ingested drug. Furthermore, the packaging should be labelled with the information about
the risk of liver damage caused by the overuse of the
drug. It also seems justifiable to use only one international name, either paracetamol or acetaminophen, and not two different names of the same drug
because it can be misleading for the patient (if not
properly informed the unaware patient can ingest the
same active substance under different names). The
most drastic proposal suggested by FDA is the withdrawal of all complex drugs, both available over the
counter (OTC) and by prescription, because, as the
various study results indicate, they are responsible,
to a great degree, for acute paracetamol poisoning.
The data obtained by the Toxic Exposure
Surveillance System (TESS) in 2005 showed that
among all acute paracetamol poisonings, 6.3% (i.e.,
3,845 of the 61,289 reported) was caused by OTC
preparations and 1.5% (41 of the 2,698 reported)
involved severe hepatic damage, while 54% of overdoses (i.e., 1,470 of the 2,698 reported) were recorded in the case of using complex drugs available by
prescription. As regards the latter drugs, it has not
been completely elucidated to which extent a narcotic ingredient present in the preparation contributed to the poisoning (76). At present, in all complex preparations available by prescription in the
USA, a single dose of contained paracetamol cannot
exceed 325 mg, whereas the way of the drug dosage,
despite a decrease in a single dose, remains the
same. Although paracetamol is not so toxic for children as for adults (children do not have a welldeveloped cytochrome P450 system so the toxic
metabolite is not formed), FDA also recommends
that liquid paracetamol should be available only in a
single established dose, e.g., 160 mg/5 mL (according to FDA information; www.fda.gov).
Another solution aimed at prevention of paracetamol hepatotoxicity in Great Britain was the introduction of tablets containing paracetamol and
methionine, which after the conversion into cysteine
and then glutathione in hepatocytes would inactivate
the active metabolite, NAPQI. Moreover, due to
such a combination, there is no time wasted from the
moment of intentional or unintentional ingestion of
a toxic dose of paracetamotol to the application of
antidote, e.g., N-acetylcysteine (hepatic damage
occurs 24 h after the overdose). Nowadays, the only
such preparation registered in Great Britain is

Paracetamol: mechanism of action, applications and safety concern

Paradote (Penn Pharmaceuticals) containing 500 mg


of paracetamol and 100 mg of methionine. Other
preparations of this type, e.g., Pameton (SmithKline
Beecham), have been withdrawn. In other European
countries and the USA such combinations of paracetamol do not exist on the pharmaceutical market
because so far no efficient and safe dosage of
methionine has been established for patients; also
safety of the long-term application of these preparations has not been investigated yet (some carcinogenic effect of methionine has been suggested).
Besides, the price of such a drug is higher than for a
preparation containing paracetamol alone (77).
In the light of novel studies, the application of
traditional NSAIDs in combination with paracetamol has not been recommended, particularly when
active substances occur in higher doses (8, 69).
Rahme et al. (69) published the retrospective cohort
study performed in 644,183 patients aged over 65
years who had been receiving paracetamol (at daily
doses: < 3 g and > 3 g) and/or traditional NSAIDs
(with or without a proton pump inhibitor) for 6
years. The risk of hospitalization due to gastrointestinal events (ulceration, perforation, bleeding
from the upper or lower segment of the digestive
tract) appeared to be two-fold higher in the case of
taking paracetamol in combination with traditional
NSAIDs as compared to NSAIDs used in monotherapy. The authors of that study (69), as well as other
researchers analyzing the problem of interaction
between paracetamol and NSAIDs (8), explain the
results in relation to the additional COX-1 inhibition
caused by paracetamol. This hypothesis seems to be
reliable in the light of new data showing that paracetamol synergistically enhances inhibitory effect of
diclofenac on platelet activity (68, 78). Thus, safety
and usefulness of complex preparations containing
paracetamol combined with NSAIDs appearing on
the pharmaceutic market are still the matter of discussion. It is worth paying attention to preparations
containing paracetamol and NSAIDs (ibuprofen and
propyphenazone) available on the Polish market
without a prescription (Cefalgin and Saridon paracetamol + propyphenazone and Metafen and
Nurofen ultima - paracetamol + ibuprofen). The
aforementioned drugs contain paracetamol at doses
of 250-500 mg and NSAIDs: ibuprofen - 200 mg or
propyphenazone - 150 mg. According to the manufacturers information, a single dose of these drugs is
1-2 tablets with the possibility of three-fold application per day. Considering the maximum dosage (2
tablets 3 times a day), a total dose of paracetamol
would range from 1.5 g to 3 g, which is in compliance with the contemporary knowledge (8, 69) if

21

used sporadically. It should be remembered that a


single dose of paracetamol should not exceed 1 g
and daily dose 4 g; the US FDA suggests these values should be decreased to 0.65 g and 3.25 g, respectively. In the case of combined application of paracetamol with NSAIDs, paracetamol dosage should
be considerably lower than the aforementioned
values.
CONCLUSIONS
Summing up, paracetamol monotherapy is efficient, well tolerated by the majority of patients and
safe, on condition that the drug is administered at
therapeutic doses. Table 1 sums up the advantages
and disadvantages of paracetamol. We should, however, bear in mind that the paracetamol overuse or
application even at therapeutic doses in some situations like improper slimming, smoking, alcohol
abuse or ingestion of other medicines may cause
severe hepatic damage or death. Therefore, the question arises as to whether the patient knows that a
safe dose of paracetamol (assuming that the abovementioned situations are not present) comprises only
eight tablets of 500 mg or four sachets, each one
containing 1000 mg, per day and that paracetamol is
hidden in other preparations under different
names (here are about 100 simple and complex
preparations in Poland). Thus, it is very important to
the patient to be warned by doctors or pharmacists
about the risk connected with the ingestion and particularly with the overuse of this drug. It appears in
the light of new data that despite frequent application of paracetamol as an efficient analgesic and
antipyretic drug, the action of this medicament has
not been completely understood and this little
unknown part may cause irreversible damage to the
organism when the drug is overused. A long-term
application of high doses of paracetamol carries the
risk of adverse reactions typical for COX-2
inhibitors (coxibs) such as hypertension, heart
infarction or renal failure. It results from a peripheral selective inhibition of COX-2 by paracetamol.
Moreover, it appears that the use of paracetamol
combined with NSAIDs is not beneficial because an
increase in the occurrence of gastrointestinal events
can be observed. On the other hand, i.v. administered paracetamol at high doses inhibits platelet
aggregation, which is very important in the treatment of patients with disorders of hemostasis.
It should be remembered that despite the fact
that paracetamol has a wide clinical application it is
not a drug devoid of side effects. Therefore, before
taking a decision about the treatment of the patient

22

MARTA JWIAK-BBENISTA and JERZY Z. NOWAK

with paracetamol, each time a balance of benefits


and losses should be made so as to perform the adequate and efficient therapy. The aim of the present
study was not to deny the rationality of paracetamol
use but only to draw the attention of doctors prescribing this drug and pharmacists selling the drug as
well patients taking it to the fact that this drug should
be used only in situations which are indispensable. In
the light of the contemporary research it is not possible to answer the question included in the title of the
present study Do we know all about paracetamol
but the nearest years will obviously provide the
answer whether the decision taken in 1956 to introduce paracetamol as an OCT drug was correct.
Acknowledgment
The study was financed by the Medical
University of d (grant no.: 503/1-23-01/503-01).
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Received: 11. 04. 2013